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Changing Organizations and Policy for Substance Abuse Treatment: Implications for HIV and Other Disorders Thomas D’Aunno, Ph.D. Columbia University Harold Pollack, Ph.D. University of Chicago HIV Center for Clinical and Behavioral Studies HIV Center for Clinical and Behavioral Studies New York State Psychiatric Institute and Columbia University June 23, 2011

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Objectives To test a comprehensive model of the diffusion (implementation) of evidence-based practices (among opioid treatment programs) Science focused on developing evidence-based practices (EBPs) has improved substantially, but the science of ensuring that new treatments and services actually reach intended patients or populations lags behind Present analyses testing part of the model using data from the National Drug Abuse Treatment System Survey (NDATSS) (NIDA-supported since 1982) Promote interest in implementation research

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Roadmap Background and conceptual approach The case of methadone (and HIV testing) as an evidence-based practice –Data and analyses: 1988-2005 National Drug Abuse Treatment System Survey (NDATSS) –Results: Descriptive, regression –Discussion: Implications for quality of care and implementation research

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Conceptual Approach: Four Models of Diffusion Socio-technical model that emphasizes how well the innovation matches the work needs and characteristics of its intended users Organizational-managerial model that emphasizes technical and social support for the innovation within its host organization Market model that focuses on the dynamics of local competition and social networks in the diffusion of innovations State regulation model that emphasizes the role of government rules that hinder or support innovation

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Conceptual Approach: How Do These Models Relate to Each Other? More work is needed to evaluate these models: –Are the effects of these models additive, such that they combine to account for the diffusion and implementation of innovations? –Or, do the key factors in each model interact, for example, even to the extent that some factors cancel the effects of others? –Do the effects of some factors mediate the effects of others, creating causal pathways?

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The Case of Methadone as an Evidence-Based Practice Many studies indicate that MMT is highly cost- effective –Studies indicate significant long-term gains in health, employment, reduced drug use, and reduced crime –Very large reduction in estimated crime costs probably larger than the costs of the program –Reduced HIV transmission, though less effective in preventing hepatitis C Well-implemented MMT appears more effective than other treatment approaches in preventing relapse or drop-out from treatment

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The Changing Role of JCAHO –2005 shows no effect vs. strong effect in earlier analyses…why? Between 2000 and 2004, accreditation by JCAHO or CARF became mandatory…early movers vs. necessary adopters The Changing Role of JCAHO

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Managerial and Staff Attitudes  Some managers and staff continue to hold attitudes inimical to high methadone doses  Against “substituting one addiction for another”  Support treatment models that discourage or limit medication-based approaches  If methadone is used in treatment, it should be used as briefly and in as low dosage as possible

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Preliminary Results from One Treatment Unit The challenge within a treatment unit to encourage higher doses and consistent practices Unit challenged by accreditation bodies to increase dose Director wants to increase doses, but not all counselors appear to agree HP examined records for 718 patients, stratified across counselors

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Descriptive Analysis of One Treatment Unit Snapshot of 718 patients, stratified by 17 members of counseling staff Clients assigned to counselors based on immediate caseloads and time of arrival Not randomized assignment, but unsystematic and based on reasons other than dose levels These are pilot data used for organizational improvement rather than research purposes

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Observations About Unit Unit-level statistics are similar to national averages –Many patients receive doses below current recommended practice guidelines This masks large variation across counselors in the same unit Counselors vary in dosing practices, though each counselor provides diverse dose levels to his/her current patients.

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Organizational Readiness for Improvement Case studies of 3 inner-city Chicago programs that are not JCAHO-accredited and have majority of African-American clients; extensive interviews and surveys Data show staff members do not have adequate knowledge or training in MMT (vs. clinical supervisors and managers) Too few staff members